What causes men to have fertility problems?

First, there are obstructive causes. These are due to sperm not being able to get to where they need to be. Infection, injury, or a physical abnormality that a man is born with (congenital) can all stop sperm being ejaculated. The good news is that some of these problems can be treated and a low sperm count reversed (Karavolos et al 2013, NCCWCH 2013).

Second, there are non-obstructive causes of low sperm. Some of these are due to unusual hormonal imbalances in the brain that affect how sperm are produced (Karavolos et al 2013). These can happen because of a problem from birth or as a result of a brain tumour, injury or brain surgery (HFEA 2015a, Karavolos et al 2013).

In many cases, it’s not obvious what causes a low sperm count. However, it’s widely accepted that excessive drinking, smoking and cannabis use can all contribute to poor-quality sperm, as can exposure to certain medications (NHS 2016b).

The same types of hormones regulate men’s and women’s reproductive systems, just in different amounts. So some of the same fertility drugs that are used to stimulate ovulation are also used to stimulate sperm production.

Male fertility drugs can only help men with fertility problems caused by a hormonal imbalance. As a result, fertility drugs are used much less frequently for male fertility problems than for female fertility problems (HFEA 2015, Karavolos et al 2013).

What are male fertility drugs and how do they work?

The main fertility drugs that are used to treat a low sperm count are injectable hormones called gonadotrophins. Gonadotrophins are used to treat men who are not producing sperm because of a condition called hypogonadotrophic hypogonadism (HFEA 2015a, Karavolos et al 2013, NCCWCH 2013). The condition occurs when the brain’s pituitary gland has difficulty making the hormones needed to produce testosterone and sperm. These hormones are called follicle-stimulating hormone (FSH) and luteinising hormone (LH) (Karavolos et al 2013).

Gonadotrophins prompt the testicles to produce testosterone and sperm directly, bypassing the brain. The main forms of gonadotrophins used for male infertility are:

Pulsatile gonadotrophin-releasing hormones (GnRH, brand name Gonadorelin) may also be used (BNF 2016, Snyder 2015).

What other drugs may be needed for male fertility problems?

Sometimes a low sperm count is caused by a condition called retrograde ejaculation. This is when sperm are ejaculated into the bladder instead of the penis, most often as a result of surgery for prostate or urethra problems, but sometimes due to diabetes, multiple sclerosis or medication for high blood pressure (NCCWCH 2013, NHS 2016a).

Hormones won’t help this, but non-hormonal drugs, such as imipramine, milodrin, chlorpheniramine or brompheniramine, may help (NCCWCH 2013). These drugs may help close the neck of the bladder during ejaculation, if the cause of the problem is diabetes or surgery, but success depends on how much damage there is to the muscles or nerves (NHS 2016a).

Antibiotics can also be recommended as a fertility treatment, when an infection or inflammation is preventing sperm moving from the testes (HFEA 2015a, NCCWCH 2013).

Are male fertility drugs suitable for all men?

It depends on what the problem is. A doctor will carry out tests to work out the cause. For example, retrograde ejaculation may be caused by certain medications. Stopping those drugs, rather than taking other drugs, may be the solution (NHS 2016a).

Hormone fertility drugs will usually only be prescribed for a low sperm count that is due to hypogonadotrophic hypogonadism (NCCWCH 2013). Sometimes, a doctor may prescribe hormone fertility drugs for poor sperm quality and its ability to move (motility) without an obvious hormonal imbalance but there’s not enough evidence to suggest that they’re effective (NCCWCH 2013).

Male fertility problems, such as a low sperm count, are increasingly treated with assisted conception techniques such as intracytoplasmic sperm injection (ICSI), where a single sperm is injected straight into an egg that has been removed from your ovaries (HFEA 2015b, NCCWCH 2013).

How long does treatment with male fertility drugs last?

For men, a cycle of human chorionic gonadotrophin (hCG) means giving yourself three injections a week, on the same three days each week, for at least six months (Snyder 2015).

If necessary, the dose of hCG can be increased and continued for another 12 months to 24 months, or extra injections of human menopausal gonadotrophin (hMG) may be needed (Snyder 2015).

How successful are male fertility drugs?

Although success is far from guaranteed, fertility drugs can help to jump-start sperm production for certain conditions. Fertility drugs can help to boost low sperm counts to normal levels (Snyder 2015). (Anything under 15 million per ml is considered low (NCCWCH 2013, NHS 2016b).)

About eight in 10 men with hypogonadotrophic hypogonadism have improved fertility or sperm counts after a course of treatment with gonadotrophins (Dwyer et al 2014, Rastrelli et al 2015).

About three in 10 patients achieve at least one pregnancy with their partner following treatment (Rastrelli et al 2015).

If medication doesn’t work to improve a low sperm count, your doctor may carry out a small operation to retrieve sperm from your testicles. If some sperm is being produced, ICSI may be an option (Dwyer et al 2014, Rastrelli et al 2015).

Different medical treatments for retrograde ejaculation seem to have similar success rates with up to about 80 per cent of men achieving pregnancy with their partner either spontaneously or through assisted conception (NCCWCH 2013).

Do male fertility drugs have any side-effects?

In men, gonadotrophins may cause:

fluid retention

headache

tiredness

mood changes

breast enlargement

acne

weight gain(BNF 2016)

These side-effects will disappear once the treatment stops.

Medical treatments for retrograde ejaculation may also cause certain side-effects:

dizziness

restlessness

dry mouth

nausea (NCCWCH 2013)

If medication doesn't work for retrograde ejaculation, other techniques, such as recovery of sperm from the urine, may be suggested (NCCWCH 2013).

You and your partner may also find fertility treatments stressful to go through. Even if you’re feeling relaxed about your chances of conceiving, your partner may not be. It's good to talk about how you’re both feeling. Many couples find that fertility counselling is a great help.

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